Last month, a doctor who serves as an ethical consultant talked to me about an escalating concern in her hospital. Physicians and nurses feel trapped, she said, by the competing demands of administrators, insurance companies, lawyers, patients’ families and even one another. And they are forced to compromise on what they believe is the right thing to do for patients. She titled the problem moral distress. Since that discussion, I have not been able to stop noticing moral distress.
Yesterday, for instance, I visited one of my closest friends, a genius and articulate nurse whom I’ll call Mary. During the long time that we worked together, I learned that Mary’s assessments of different clinical situations were nearly always correct. But I also noticed that over time, she would often resort to obscure speech or writing and noncommittal statements when expressing her opinions to doctors and supervisors. Soon after we met, for instance, Mary began taking care of a transplant patient admitted with an infected abdominal hernia repair. By the time I had come to be one of the residents on this patient’s surgical team, he had been living in the I.C.U. for a month and his abdominal wall, or what was left of it, had become a beehive of festering bacterial pockets.
One morning, after yet another attempt in the O.R. to clear the infected pockets, Mary pulled me aside. How much more can a person take? she asked. Over the next few days, Mary asked the same question to the rest of the surgical team.
When it finally became apparent that nobody on the team was listening to her concerns, Mary’s question changed. If a doctor asked her to prepare the patient for yet another trip to the O.R., she would ask back, What do you want me to do? Or she would reply, What did you say? Or she would step away, her response trailing behind. O – kay. As time went on, Mary stopped answering at all. She just simply went about her routines in the most superficial of ways, and her usually bright personality became flat.
I finally asked her what was the problem. If I say anything at all, I get into trouble, she explained, looking up from her charting work. Doctors think I am out of line, and I get warnings from my superiors about being unprofessional. But if I keep my mouth shut, I’m afraid that the patient might suffer. Her eyes drifted over toward our patient. What can I do? she asked.
Moral distress, knowing what is ethically appropriate but not being able to act on it because of obstacles inherent in a situation was first described in 1984 in a book on nursing ethics. Subsequent researchers focused primarily on the experiences of nurses and found that those who suffered from moral distress often became reluctant to interact with patients and other providers. In one recent study, 15 percent of nurses left their jobs because of moral distress.
It now appears that doctors caught between moral obligations to patients and the demands of insurance companies, administrators and even, occasionally, patients’ families are feeling increasingly cornered and unable to do what they know is morally correct. Scientists from the University of Virginia recently studied I.C.U. doctors and nurses and found that even though physicians on average are less frustrated than nurses, they can also suffer from intense moral distress.
This discovery doesn’t surprise me. It is profoundly disheartening to argue with disembodied voices over the phone over insurance approval for surgeries to remove cancers, to struggle to do everything that we should be obligated to do for the rising numbers of patients a single doctor must see, and to follow the wishes of estranged relatives who swoop into the hospital during the last days of life and demand aggressive treatment.
What can we do?
I spoke with Ann B. Hamric, a registered nurse and the lead author of the research on I.C.U. doctors and nurses. There are many reasons why a clinician can sometimes feel that he or she is not able to do the ethically appropriate thing, Dr. Hamric said over the phone. A lot of the reasons for moral distress come from the environments where we are employed. Are we working as respectful partners or are we afraid? Doctors feel that the risk managers or the lawyers are telling them what they can and cannot do for patients, and that affects doctors. We discussed the implications of moral distress for the current nursing shortage and the impending primary care shortage. I asked her if there might be any way to change the work environment. Part of what we have to do, Dr. Hamric answered, is to start recognizing moral distress and purposly talking about it in health care settings. Otherwise, we will fail to recognize the damage to the integrity of the provider. We can’t expect an individual to work in this kind of highly intense, emotional, intimate space and then expect them to tolerate threats to their professional integrity. She added, There’s Nobody that’s going to stay otherwise. It’s just too heartbreaking.
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